Case series of children with steroid-Induced glaucoma.

Steroid-induced glaucoma is the most serious complication of the injudicious use of steroids, particularly among children affected by allergic conjunctivitis. This condition is steroid-dependent, and children are commonly being prescribed topical anti-inflammatories, including topical steroids, by general practitioners. Furthermore, topical steroids are also available over the counter, and this availability contributes to overuse without proper monitoring by an ophthalmologist. We present a series of five cases illustrating the devastating effect of unmonitored, long-term use of steroids among children for vernal keratoconjunctivitis. The medications were prescribed initially by general ophthalmologists and were continually bought over the counter by parents. At the presentation to our center, these patients were already compromised visually, exhibiting glaucomatous optic disc changes and high intraocular pressure. The series highlights the optic nerve damage resulting in irreversible visual compromises among children on long-term, topical steroids and the importance of regular monitoring with a low threshold for ophthalmologist referral.

Plasma extracellular vesicle protein content for diagnosis and prognosis of global cardiovascular disease.

Cardiovascular disease is a major public health problem worldwide. Its growing burden is particularly ominous in Asia, due to increasing rates of major risk factors such as diabetes, obesity and smoking. There is an urgent need for early identification and treatment of individuals at risk of adverse cardiovascular events. Plasma extracellular vesicle proteins are novel biomarkers that have been shown to be useful in the diagnosis, risk stratification and prognostication of patients with cardiovascular disease. Ongoing parallel biobank initiatives in European (the Netherlands) and Asian (Singapore) populations offer a unique opportunity to validate these biomarkers in diverse ethnic groups.

Metabolic syndrome, endothelial injury, and subclinical atherosclerosis in patients with systemic lupus erythematosus.

OBJECTIVES: To study the link between metabolic syndrome (MetS), endothelial injury, and atherosclerosis in patients with systemic lupus erythematosus (SLE). METHODS: Consecutive SLE patients without a history of arterial thrombosis were screened for atherosclerosis at the carotid and coronary arteries by B-mode ultrasound [intima-media thickness (IMT)] and multidetector computed tomography (MDCT) scan (Agatston calcium scores), respectively. Plasma levels of homocysteine, high-sensitivity C-reactive protein (hsCRP), soluble vascular cell adhesion molecule (sVCAM)-1, P-selectin, and soluble thrombomodulin (sTM) were assayed. Patients were stratified according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria for MetS, using the Asian criteria for abdominal obesity. Risk factors for atherosclerosis were studied. RESULTS: Of the 123 SLE patients (93% women; age 47.9+/-11 years; SLE duration 10.9+/-7.0 years) studied, 20 (16.3%) had MetS. The prevalence of MetS in the SLE patients was significantly higher than in 492 age- and sex-matched healthy controls (9.6%; p=0.03). Coronary calcification and abnormal carotid IMT were detected in 38 (31%) and 72 (59%) of SLE patients, respectively. Patients with MetS had a significantly higher Agatston score (69.5+/-95 vs. 16.4+/-57; p=0.03) and a numerically higher carotid IMT (p=0.43) than those without. In a logistic regression model, the MetS [odds ratio (OR) 3.11, 95% confidence interval (CI) 1.01-9.59, p=0.049] was associated with coronary atherosclerosis after adjustment for age and other risk factors. In addition, patients with MetS had significantly higher levels of hsCRP (p=0.002), homocysteine (p=0.03), and sTM (p=0.01). CONCLUSIONS: The MetS is more prevalent in SLE patients than the general population and is associated with endothelial injury and coronary atherosclerosis. More aggressive control of risk factors is justified in these patients.

Rovibronically selected and resolved two-color laser photoionization and photoelectron study of the iron carbide cation.

By using a two-color laser excitation-photoionization scheme, we have obtained rovibronically selected and resolved state-to-state pulsed field ionization-photoelectron (PFI-PE) bands for FeC+(X2delta5/2; v+=0-2, J+), allowing unambiguous rotational assignments for the photoionization transitions. The finding of the J+ = 5/2 level as the lowest rotational state confirms that the ground FeC+ ion state is of 2delta5/2 symmetry. The observed changes in total angular momentum upon photoionization of FeC are |deltaJ+| = |J+ - J'|

Disseminated strongyloidiasis: a retrospective study of clinical course and outcome.

A retrospective study was carried out to evaluate the clinical course and outcome of disseminated strongyloidiasis treated in a regional hospital in Hong Kong over a 10-year period. Seven cases were identified, and the case history of each patient was analysed. The most common presenting symptom was fever (100%). Five (71%) patients had gastrointestinal symptoms, the most common being abdominal pain and diarrhoea. Three (42%) patients had a significant drop in haemoglobin. Six (85%) patients had bronchoalveolar infiltrates on chest radiographs. Most patients were immunosuppressed by means of steroid treatment for their underlying primary disease. One patient was diabetic, and another had lymphoma and was receiving chemotherapy. Strongyloides larvae were identified in stool specimens in two patients, in sputum smears in two patients, and in gastric biopsies in three patients. Five (71%) of the patients with lung involvement progressed to respiratory failure and died. Two (29%) cases were complicated by gram-negative bacterial infection. No patient had eosinophilia on presentation. All patients received antihelminthic treatment of variable duration. The case fatality rate in the cohort was 71% despite aggressive supportive therapy. Pulmonary and bowel symptoms were prominent in our series. In conclusion, the diagnosis of disseminated strongyloidiasis is often delayed because of nonspecific presenting symptoms. Early diagnosis relies on a high index of clinical suspicion, especially in immunocompromised hosts. Screening for Strongyloides infection before the initiation of immunosuppressive therapy should be considered, especially in endemic areas.

Coronary artery ectasia: a ten-year experience in a tertiary hospital in Singapore.

INTRODUCTION: Coronary artery ectasia (CAE) is a well-recognised, albeit rare, angiographic finding of abnormal coronary dilatation. To our best knowledge, its incidence has never been described in Singapore. We aimed to determine the incidence of CAE at our teaching hospital and to describe patient and angiographic characteristics. MATERIALS AND METHODS: Cases were identified through a search of our hospital's computer database and all records were reviewed. RESULTS: Over the 10-year study period (1992-2001), 8641 patients underwent coronary angiography. CAE was diagnosed in 104 patients, giving an incidence of 1.2%. The majority (74%) were male. The median age was 54 years (range, 25 to 79 years). Sixty-six per cent of patients were Chinese, 19% Malays, 12% Indians and 3% other races. Concomitant diabetes mellitus was present in 31%, hypertension in 58% and dyslipidaemia in 63% of patients. Co-existent obstructive coronary artery disease was present in 82% of cases. The frequency of arterial involvement was: right coronary artery (RCA), 65%; left anterior descending artery (LAD), 48%; circumflex artery (CX), 43%; and left main artery (LM), 2%. CAE affected only 1 major vessel in 62% of cases and all 3 vessels in 20%. Eighteen patients were advised to undergo bypass surgery, while percutaneous coronary intervention was recommended in 26 patients. CONCLUSIONS: The incidence of ectasia was 1.2%. The majority of patients were males in their sixth decade with underlying dyslipidaemia or hypertension. CAE was associated with obstructive coronary artery disease in more than 80% of cases. The RCA was most commonly affected and most patients had single vessel involvement.

Traveling through the cancer trajectory: social support perceived by women with gynecologic cancer in Hong Kong.

A qualitative research design was selected to gather data on the experiences of social support for Chinese women with gynecologic cancer. Eighteen women were recruited and interviewed at an oncology unit of a teaching hospital in Hong Kong. Content analysis of the interview data showed Chinese women with gynecologic cancer placed enormous emphasis on their human relationships. Family members were especially significant to them although not all identified their family relations as satisfactory or helpful. Their social network comprised 4 major sources, including family and friends, work and colleagues, health professionals, and religion and spiritual beliefs. Each network offered significant reciprocal relations, authoritative relations, or entrusting relations. The positive appraisal of the support function was linked to the Chinese value of food, work ethics, the Confucian and religious philosophy, whereas negative aspects of support, such as the stress of maintaining relationships and inadequate information, conjoined with the Chinese suppression of emotion and the busyness of health professionals. Future studies, including social relations as a determinant, should ensure a broad and multifunctional view of social support and acknowledge the cultural influences on the perspective of support.

Fatal chemotherapy associated Clostridium difficile infection--a case report.

Clostridium difficile associated diarrhoea or Pseudomembranous colitis occasionally occurs without prior antibiotic usage. While the association of chemotherapy and Clostridium difficile infection has previously been well recorded, the true incidence is unknown. We report a case of Clostridium difficile associated diarrhoea after chemotherapy for lung cancer. The fatal outcome in this case and the increasing use of chemotherapy in this country highlights the need to have a high index of suspicion in any case of unexplained diarrhoea post chemotherapy. A review of the literature is presented.

Strongyloidiasis as a possible cause of nephrotic syndrome.

Chronic strongyloidiasis is a mild disease and has never been reported to be associated with nephrotic syndrome. Disseminated strongyloidiasis is known to have high mortality, but it frequently is not diagnosed until autopsy. We report a patient with nephrotic syndrome developing disseminated strongyloidiasis after steroid therapy. The findings in renal biopsy, the time course of the development, and resolution of nephrotic syndrome after thiabendazole treatment suggested a possible causal relationship between chronic strongyloidiasis and nephrotic syndrome. The case also demonstrated the importance of early diagnosis in disseminated strongyloidiasis and the good clinical outcome of early treatment before the development of organ failure.

Cancer pain management: a recent experience by anaesthesiologists in a teaching hospital in Hong Kong.

More than 60% of cancer patients suffers from unbearable pain, especially towards their terminal stages. Anaesthesiologists are involved in cancer pain management because of their expertise in analgesic pharmacology and neurolytic procedures. This manuscript reported on the experience of treating cancer pain in Chinese patient in Hong Kong with reference to current literature in other parts of the world. One hundred and sixty two Chinese patients were referred from other specialists to the Department of Anaesthesiology, Queen Mary Hospital for further management because of their cancer pain control were considered difficult. Upon referral, the mean visual analogue scale of pain (VAS) was 5.8 +/- 2.7. The pain caused insomnia (66.7%) and appetite loss (45%) as well. By far most (80%) patients' pain were successively controlled with oral systemic analgesics. These were prescribed in form of a combination of NSAID (72.2%), potent opioids (76.5%) and co-analgesics (21.6%). In our series, the mean oral morphine (MS Continus) requirements was 96.0 +/- 68.3 mg on discharge. Frequent nausea and constipation persisted in 16.0% and 8.0% respectively despite active treatment with anti-emetics and laxatives. Twenty eight neurolytic blocks was performed in 22 (13.6%) patients. Good pain relief was achieved in 78.6%. Overall speaking most patients (90.7%) were able to achieve adequate analgesia before death.

Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens.

Sixty-four patients undergoing oesophageal surgery were randomly allocated to receive either a continuous lumbar epidural infusion of morphine or fentanyl, or, intramuscular morphine for postoperative analgesia. There was no statistical difference in analgesic requirements between the patients who underwent a thoracotomy for their procedure (n = 50) and those who did not (n = 14), as assessed by the total dose of opioid administered, visual analogue scale (VAS) and pain score (PS) comparison. However, by these criteria, epidural morphine infusion provided the most satisfactory analgesia (P less than 0.05). Despite the variable quality of analgesia achieved with the three regimens, the postoperative lung function tests were similar for all groups, and we conclude that routine lung function tests are not an appropriate method of comparing analgesic efficacy. Prophylactic administration of loratadine to 15% of our patients was not shown to be effective in diminishing the incidence of pruritus.

A comparison of two-lung high frequency positive pressure ventilation and one-lung ventilation plus 5 cm H2O non-ventilated lung CPAP, in patients undergoing anaesthesia for oesophagectomy.

A randomised prospective controlled study was conducted during a one-year period on patients scheduled for oesophagectomy via a right thoracotomy approach. Twenty-two patients received one-lung ventilation (OLV group) and twenty patients received high frequency positive pressure ventilation (HFPPV group). Episodic hypoxaemia (SaO2 less than 90% for greater than 30 seconds, FiO2 1.0) occurred in eleven patients in the OLV group and six patients in the HFPPV group. No patient in the HFPPV group had a severe desaturation episode (SaO2 less than 80%, FiO2 1.0) compared with nine patients in the OLV group (P less than 0.05). The mean peak inspiratory pressure and average mean airway pressure were significantly lower in the HFPPV group 28.8 (SD 7.7) and 7.2 (SD 2.4) cm H2O respectively, compared with the OLV group, 40.0 (SD 9.9) and 11.9 (SD 4.9) cm H2O (P less than 0.05). Two-lung high frequency positive pressure ventilation has some advantages over one-lung ventilation during the thoracotomy phase of oesophagectomy because it is easy to administer, does not significantly compromise the surgical exposure and is associated with fewer severe undesirable physiological disturbances.